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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/surgical-complication-prevention/bim.docx
December 01, 2017 - Barrier Identification and Mitigation Tool
AHRQ Safety Program for Surgery
AHRQ Safety Program for Surgery
Barrier Identification and Mitigation Tool
Introduction
Problem Statement
Guidelines summarizing evidence exist to help ensure that patients receive recommended interventions. In addition, consistent guidel…
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psnet.ahrq.gov/node/49814/psn-pdf
December 01, 2017 - Miscommunication in the OR Leads to Anticoagulation
Mishap
December 1, 2017
Solsky I, Haynes AB. Miscommunication in the OR Leads to Anticoagulation Mishap. PSNet [internet].
2017.
https://psnet.ahrq.gov/web-mm/miscommunication-or-leads-anticoagulation-mishap
The Case
A 63-year-old man with a history of coronary…
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effectivehealthcare.ahrq.gov/sites/default/files/wysiwyg/white-paper-standardized-library.pdf
February 01, 2019 - AAOS)
Affects significant proportion
of orthopedic patients
Approximately 254,000 hip
replacement surgeries … 4)
Registries†
(5)
Other Related Work
Robotic surgery In 2012, approximately
400,000 robotic surgeries … The rate of robotic surgeries
is increasing 25% annually. … assisted hernia
repair, 1 treatment of low-risk
pharyngeal cancer, 1 pediatric
scoliosis, 2 spinal surgeries … Freehand Minimally Invasive Spinal
Surgeries
Doron Dinstein
NASS Spine Registry Pam Hayden
Nuvasive
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www.ahrq.gov/sites/default/files/wysiwyg/funding/fund-opps/smith-angela-r13-hs026679-01.pdf
March 31, 2020 - heterogeneity in post-operative opioid prescribing patterns, even among patients receiving similar
surgeries … heterogeneity in post-operative opioid prescribing patterns, even among patients receiving similar
surgeries … opioid-sparing analgesia strategies, and variation in opioid
prescribing patterns for various urologic surgeries
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hcup-us.ahrq.gov/reports/methods/2005_05.pdf
January 01, 2005 - NUMBER OF SURGERIES BY STATE AND BODY SYSTEM, 2001 SASD
contact.pdf
EXECUTIVE SUMMARY
INTRODUCTION … NUMBER OF SURGERIES BY STATE AND BODY SYSTEM, 2001 SASD
Subhead: Methods Applying AHRQ Quality Indicators
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www.ahrq.gov/hai/tools/surgery/how-to-use.html
December 01, 2017 - How To Use the Toolkit
Toolkit To Promote Safe Surgery
The toolkit has two complementary guides that should be used together and are a good starting point: Applying CUSP To Promote Safe Surgery , and Surgical Complication Prevention . These two guides address adaptive and technical work, which are both crit…
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psnet.ahrq.gov/issue/patient-guide-10-ways-improve-communication-your-doctor
April 16, 2018 - Journal Article
Patient Guide: 10 Ways to Improve Communication with Your Doctor.
Citation Text:
Patient Guide: 10 Ways to Improve Communication With Your Doctor. J Patient Saf. 2008;1(4). doi:10.1097/01.jps.0000199856.82316.50.
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Format:
DOI Google Scholar Bi…
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psnet.ahrq.gov/web-mm/inadequate-preanesthetic-evaluation-airway-trouble
November 01, 2023 - Inadequate Preanesthetic Evaluation, Airway Trouble
Citation Text:
Blitz J. Inadequate Preanesthetic Evaluation, Airway Trouble. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2018.
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Format:
Google Scholar …
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psnet.ahrq.gov/web-mm/endotracheal-tube-fallout-patient-severe-obesity-during-eye-surgery
January 29, 2021 - Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.
Citation Text:
Bohringer C. Endotracheal Tube Fallout in a Patient with Severe Obesity During Eye Surgery.. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services.…
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www.ahrq.gov/sites/default/files/2024-03/connolly-report.pdf
January 01, 2024 - Final Progress Report: Topical Vancomycin for Neurosurgery Wound Prophylaxis
Title: Topical Vancomycin for Neurosurgery Wound Prophylaxis
Principal Investigator: Connolly, Edward Sander
Team Members:
Jared Knopman, MD - Site PI (Cornell)
Emilia Bagiella, PhD - Site PI (Mount Sinai)
Franklin Lowy, MD - Co-Investigato…
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psnet.ahrq.gov/sites/default/files/import/webmm.ahrq.gov.113_slideshow.ppt
January 01, 2006 - Spotlight Case [MONTH] 2003
Spotlight Case January 2006
An Ounce of Prevention
Source and Credits
This presentation is based on the Jan. 2006
AHRQ WebM&M Spotlight Case
See the full article at http://webmm.ahrq.gov
CME credit is available through the Web site
Commentary by: Nils Kucher, MD; University Ho…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/surgery/tools/applying-cusp/learn_from_defects.docx
December 01, 2017 - Learn From Defects Tool
AHRQ Safety Program for Surgery
Learn From Defects Tool – Perioperative Setting
What is a defect? A defect is any event or situation that you don’t want to repeat. This could include an incident that caused patient harm or put patients at risk for harm, such as a patient fall.
Problem statem…
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effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-260-improved-cancer-outcomes-executive-summary_0.pdf
May 01, 2023 - Executive Summary - Nutrition as Prevention for Improved Cancer Outcomes: Comparative Effectiveness Review No. 260
Comparative Effectiveness Review
Number 260
Nutrition as Prevention for Improved
Cancer Health Outcomes
Executive Summary
Main Points
• Two decades of randomized trial evidence from 206 studies o…
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psnet.ahrq.gov/issue/automation-failures-and-patient-safety
November 21, 2012 - Review
Automation failures and patient safety.
Citation Text:
Ruskin KJ, Ruskin AC, O’Connor M. Automation failures and patient safety. Curr Opin Anaesthesiol. 2020;33(6):788-792. doi:10.1097/aco.0000000000000935.
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DOI Google Scholar BibTeX EndNote X3 X…
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psnet.ahrq.gov/issue/patient-safety-movement-history-and-future-directions
February 21, 2015 - Review
Patient safety movement: history and future directions.
Citation Text:
Lark ME, Kirkpatrick K, Chung KC. Patient Safety Movement: History and Future Directions. J Hand Surg Am. 2018;43(2). doi:10.1016/j.jhsa.2017.11.006.
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DOI Google Scholar BibTe…
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psnet.ahrq.gov/issue/speaking-when-doctors-navigate-medical-hierarchy
August 19, 2020 - Commentary
Speaking up—when doctors navigate medical hierarchy.
Citation Text:
Srivastava R. Speaking up--when doctors navigate medical hierarchy. New Engl J Med. 2013;368(4):302-305. doi:10.1056/NEJMp1212410.
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Format:
DOI Google Scholar PubMed BibTeX EndNote…
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psnet.ahrq.gov/issue/consensus-based-recommendations-standardizing-terminology-and-reporting-adverse-events
December 22, 2018 - Commentary
Consensus-based recommendations for standardizing terminology and reporting adverse events for emergency department procedural sedation and analgesia in children.
Citation Text:
Bhatt M, Kennedy RM, Osmond MH, et al. Consensus-Based Recommendations for Standardizing Terminol…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/sustainability-tool.docx
May 01, 2017 - AHRQ Safety Program for Ambulatory Surgery
Module 4: Sustainability
Sustainability Tool
Background: This tool can be used to identify sustainability issues in planning and implementing your improvement efforts.
How to use this tool: The Implementation Team leader (or individual designated by the leader) should comple…
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/hais/tools/ambulatory-surgery/sections/sustainability/training-tools/training-tools-material-guide.docx
May 01, 2017 - Overview
Definition of Sustainability and its Importance in Quality Improvement
· Slides 4-8
Linking Sustainability and Spread
· Slides 9-10
Planning Early for Sustainability
· Slides 11-12
Barriers and Solutions to Sustaining Improvements
· Slides 13-17
Steps to Creating and Implementing a Sustainability Plan
· Slides…
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psnet.ahrq.gov/issue/video-technology-advance-safety-operating-room-and-perioperative-environment
April 27, 2010 - Commentary
Video technology to advance safety in the operating room and perioperative environment.
Citation Text:
Xiao Y, Schimpff S, Mackenzie CF, et al. Video technology to advance safety in the operating room and perioperative environment. Surg Innov. 2007;14(1):52-61.
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